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Successful anesthesia in a patient with a history of cardiac arrest following rocuronium injection.

Chung W, Jang D, Park SI, Lee WH, Yoon SH - Korean J Anesthesiol (2014)

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.

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After being transferred to the intensive care unit (ICU), ST segment depression was discovered in multiple electrocardiogram (ECG) leads and immediate coronary angiography revealed variant angina... After careful evaluation of the patient's severe anaphylactic reaction, the patient was successfully anesthetized four weeks later... Endotracheal intubation was immediately performed, and although there was no increase in airway resistance, BP continued to be severely hypotensive... The patient did not respond to intravenous ephedrine (10 mg) or phenylephrine (100 µg)... Coronary angiography was immediately performed, and the patient was diagnosed with variant angina... Reitter et al. reported several factors associated with severe symptom: emergency operation, elderly and obese patients, history of hypertension, other cardiovascular disease and/or beta-blocker use... In our present case, there was a significant increase in cardiac enzymes, ST depression was observed in multiple ECG leads and the patient was diagnosed with variant angina through coronary angiography... Even though we did not discover changes in the ST segment directly after rocuronium injection, this could have been due to limited ECG monitoring... Only the II lead was monitored during induction, while ST depression was found in the I, aVL and V2-6 leads in the ICU... The decision was made to delay the operation by four weeks... Cisatracurium was selected as the neuromuscular blocking agent due to negative results during the skin prick test and intradermal test (Fig. 1)... Although some recommend a period of six weeks after the anaphylactic event, tests were performed early due to the patients' strong desire for an early operation... In conclusion, anesthesiologists must always pay special attention during the induction period due to the administration of various drugs over a relatively short period.

No MeSH data available.


Skin prick and intradermal test performed after three weeks and four weeks after the anaphylactic event. (A, B) Skin prick and intradermal test results at three weeks. Only rocuronium shows positive results. (C, D) Skin prick and intradermal test results at four weeks. Vecuronium also shows positive results in the intradermal test.
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Figure 1: Skin prick and intradermal test performed after three weeks and four weeks after the anaphylactic event. (A, B) Skin prick and intradermal test results at three weeks. Only rocuronium shows positive results. (C, D) Skin prick and intradermal test results at four weeks. Vecuronium also shows positive results in the intradermal test.

Mentions: An 82-year-old male (height 169 cm, weight 67 kg) without any past medical history was scheduled for elective laparoscopyassisted distal gastrectomy. Although the preoperative ECG showed several premature ventricular contractions per minute, echocardiography results were normal. During induction, there was a sudden drop in blood pressure (BP) after rocuronium injection. Endotracheal intubation was immediately performed, and although there was no increase in airway resistance, BP continued to be severely hypotensive. The patient did not respond to intravenous ephedrine (10 mg) or phenylephrine (100 µg). Three minutes after the onset of hypotension, skin rash appeared over the entire body in addition to swelling of the eyes. As hemodynamics continued to deteriorate, epinephrine (200 µg) was administered and cardiopulmonary resuscitation (CPR) was initiated. Rapid crystalloid fluid infusion was given after inserting a central venous catheter in the left subclavian vein. CPR was continued for 15 minutes and epinephrine (1 mg) was injected twice over a three-minute period. The patient was also defibrillated due to one episode of ventricular fibrillation during CPR. Hydrocortisone (250 mg) and chlorpheniramine (4 mg) were also injected, while epinephrine and dopamine were continuously infused. The patient was transferred to the ICU after full recovery of consciousness and muscle tone. Twenty-four hours after the event, cardiac enzymes had elevated (Troponin I 5.24 ng/ml, CK-MB 23.5 ng/ml) and ST depression could be seen in the I, aVL, and V2-6 leads of the ECG. Coronary angiography was immediately performed, and the patient was diagnosed with variant angina. Fortunately, the patient recovered without any complications and the operation was delayed by four weeks. Intradermal injection tests were performed twice: at three weeks and at four weeks after the event (Fig. 1). Due to the positive results with rocuronium and vecuronium, cisatracurium was used instead. Intravenous injection of chlorpheniramine (4 mg) was added as premedication. There was no particular event during the second induction period, and the patient was discharged one week later.


Successful anesthesia in a patient with a history of cardiac arrest following rocuronium injection.

Chung W, Jang D, Park SI, Lee WH, Yoon SH - Korean J Anesthesiol (2014)

Skin prick and intradermal test performed after three weeks and four weeks after the anaphylactic event. (A, B) Skin prick and intradermal test results at three weeks. Only rocuronium shows positive results. (C, D) Skin prick and intradermal test results at four weeks. Vecuronium also shows positive results in the intradermal test.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
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Figure 1: Skin prick and intradermal test performed after three weeks and four weeks after the anaphylactic event. (A, B) Skin prick and intradermal test results at three weeks. Only rocuronium shows positive results. (C, D) Skin prick and intradermal test results at four weeks. Vecuronium also shows positive results in the intradermal test.
Mentions: An 82-year-old male (height 169 cm, weight 67 kg) without any past medical history was scheduled for elective laparoscopyassisted distal gastrectomy. Although the preoperative ECG showed several premature ventricular contractions per minute, echocardiography results were normal. During induction, there was a sudden drop in blood pressure (BP) after rocuronium injection. Endotracheal intubation was immediately performed, and although there was no increase in airway resistance, BP continued to be severely hypotensive. The patient did not respond to intravenous ephedrine (10 mg) or phenylephrine (100 µg). Three minutes after the onset of hypotension, skin rash appeared over the entire body in addition to swelling of the eyes. As hemodynamics continued to deteriorate, epinephrine (200 µg) was administered and cardiopulmonary resuscitation (CPR) was initiated. Rapid crystalloid fluid infusion was given after inserting a central venous catheter in the left subclavian vein. CPR was continued for 15 minutes and epinephrine (1 mg) was injected twice over a three-minute period. The patient was also defibrillated due to one episode of ventricular fibrillation during CPR. Hydrocortisone (250 mg) and chlorpheniramine (4 mg) were also injected, while epinephrine and dopamine were continuously infused. The patient was transferred to the ICU after full recovery of consciousness and muscle tone. Twenty-four hours after the event, cardiac enzymes had elevated (Troponin I 5.24 ng/ml, CK-MB 23.5 ng/ml) and ST depression could be seen in the I, aVL, and V2-6 leads of the ECG. Coronary angiography was immediately performed, and the patient was diagnosed with variant angina. Fortunately, the patient recovered without any complications and the operation was delayed by four weeks. Intradermal injection tests were performed twice: at three weeks and at four weeks after the event (Fig. 1). Due to the positive results with rocuronium and vecuronium, cisatracurium was used instead. Intravenous injection of chlorpheniramine (4 mg) was added as premedication. There was no particular event during the second induction period, and the patient was discharged one week later.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

After being transferred to the intensive care unit (ICU), ST segment depression was discovered in multiple electrocardiogram (ECG) leads and immediate coronary angiography revealed variant angina... After careful evaluation of the patient's severe anaphylactic reaction, the patient was successfully anesthetized four weeks later... Endotracheal intubation was immediately performed, and although there was no increase in airway resistance, BP continued to be severely hypotensive... The patient did not respond to intravenous ephedrine (10 mg) or phenylephrine (100 µg)... Coronary angiography was immediately performed, and the patient was diagnosed with variant angina... Reitter et al. reported several factors associated with severe symptom: emergency operation, elderly and obese patients, history of hypertension, other cardiovascular disease and/or beta-blocker use... In our present case, there was a significant increase in cardiac enzymes, ST depression was observed in multiple ECG leads and the patient was diagnosed with variant angina through coronary angiography... Even though we did not discover changes in the ST segment directly after rocuronium injection, this could have been due to limited ECG monitoring... Only the II lead was monitored during induction, while ST depression was found in the I, aVL and V2-6 leads in the ICU... The decision was made to delay the operation by four weeks... Cisatracurium was selected as the neuromuscular blocking agent due to negative results during the skin prick test and intradermal test (Fig. 1)... Although some recommend a period of six weeks after the anaphylactic event, tests were performed early due to the patients' strong desire for an early operation... In conclusion, anesthesiologists must always pay special attention during the induction period due to the administration of various drugs over a relatively short period.

No MeSH data available.